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2023 Dog Registration Form
Please complete 1 form for each dog that you intend to show
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Email
*
Your email
Special Considerations
Super Senior
Graduating Senior
Cloverbud
Differently Abled
4-H Member Information
Member's First Name
*
Your answer
Member's Last Name
*
Your answer
4-H Age (Age as of Jan 1st, 2023)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Street Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
Parent(s)/Guardian(s)
*
Your answer
Parent(s) Phone
*
Your answer
Parent(s) Email
*
Your answer
4-H Club
*
Your answer
4-H Dog Information
Dog's Name
*
Your answer
Dog's Sex
*
Male
Female
Dog's Breed
*
Your answer
Neutered/Spayed
*
Yes
No
Vaccination Information
IMMUNIZATIONS: A copy of each dog's immunization record is required
REQUIRED: Distemper/Parvovirus/Adenovirus (Hepatitis), Rabies, & Leptospirosis
RECOMMENDED: Bordetella
Distemper/Parvovirus/Adenovirus (Hepatitis) Expiration Date
*
MM
/
DD
/
YYYY
Rabies Expiration Date
*
MM
/
DD
/
YYYY
Leptospirosis Expiration Date
*
MM
/
DD
/
YYYY
Bordetella Expiration Date
MM
/
DD
/
YYYY
Dog Registrations are due: June 5th, 2023
A copy of your responses will be emailed to the address you provided.
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